Research in medical school: The need to align incentives with value

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It is a truism of American medical education that students should do research. Stanford medical school’s website espouses a “strong commitment to student research,” because it makes us “valued members of any medical field.” A similar message can be found at almost any other institution. It’s not just medical school either. Many undergraduate programs tout their research offerings for pre-med students, while residencies and fellowships often encourage their trainees to pursue investigatory projects.

There are several reasons for the emphasis on research in medical training. One obvious explanation is that schools want to prepare students for a career in academic medicine, through which physicians can combine scientific discovery with clinical insight to drive medicine forward. More broadly speaking, research is a way to develop analytic and critical thinking skills. These abilities not only help students better understand disease – they teach us how to read and interpret scientific literature to keep up to date with the latest advances in the field.

I believe in the value of engaging in research, but I recently came across the work of two prominent academic physicians who question whether it accomplishes these goals. The first is Ezekiel Emanuel. While he may be best known for his work on the Affordable Care Act as a special advisor to the White House, Emanuel’s background is in academics. After completing an MD/PhD at Harvard, he stayed on as an associate professor; he’s now a vice provost and professor at the University of Pennsylvania.

In his book, Reinventing American Health Care, Emanuel discusses how to make medical education more effective, and he specifically targets the research paradigm as an inefficiency. Whether or not it is explicitly stated, many top-tier programs require their students to do research in addition to their clinical training. To Emanuel, this constitutes “exploitation of trainees for no improvement in clinical skills.” He argues that eliminating such requirements can streamline medical education and boost the physician workforce. The physician shortage is one of the most discussed problems in health care. Trimming the length and cost of training can help address it. Reducing research requirements would allow students to prioritize their clinical work or other relevant interests.

“Exploitation” is perhaps an overstatement, but Emanuel addresses a legitimate concern about whether students’ time is best spent on research. And findings from researchers like Stanford’s John Ioannidis, MD, amplify the concern.

Ioannidis is a professor of health research and policy and co-director of the Meta-Research Innovation Center at Stanford. Prior to his arrival at Stanford, he completed medical school in Greece and subsequently held positions at a variety of American academic institutions, including Harvard, Johns Hopkins, and Tufts. Ioannidis has carved out an unusual niche for himself in the world of academia. Specifically, he studies the validity of medical research – and the results are interesting, to say the least.

He rose to prominence with a 2005 paper in PLoS Medicine, provocatively titled “Why Most Published Research Findings are False” (the title sums up the paper – incidentally the journal’s most downloaded research paper ever). He followed that up with a study in JAMA, which found that even the most cited and highly regarded papers in medicine often have incorrect or exaggerated results. (Somewhat ironically, Ioannidis himself is one of the most cited scientists in the world).

Ioannidis believes the problems with medical research stem from its incentive structure. While no one intends to conduct flawed science, the fact is that grant money, publications, and professional advancement accrue to those who publish frequently and produce splashy results, whether or not those results hold up to scrutiny. Ioannidis is hardly the first person to point this out, but he’s one of few to have compelling data to back up his claims.

The juxtaposition of Ioannidis and Emanuel’s arguments brings up some interesting questions. Ioannidis notes that the competitive academic environment is designed to reward research prowess. Emanuel points out that medical students are required to traverse this environment even though the vast majority of physicians do not pursue research careers. Does this result in the generation of low-quality research that does not help students become better clinicians? Do we end up diverting money and other resources away from good research? And if so, how can we fix the system?

It’s difficult to answer these questions. Research is an extraordinarily important aspect of medicine. It allows us to develop the tools and techniques that help our patients and establishes the guidelines that direct physician decision-making. But patient care and other dimensions of medicine are important too. As such, it’s worth taking the time to optimize incentives to maximize the effectiveness of medical training.

This piece is re-posted courtesy of the Stanford School of Medicine’s medical blog Scope. It is part 1 of a three-part series: read Part 2 here and Part 3 here. Read the original piece and check out more writing on Scope here.